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Stanford Medicine 25 Blog

Examination of the Hand (The Hand in Diagnosis)

The examination of the hand and nails can lead to a number of diagnoses. Some of these include liver disease (Terry's nails), kidney disease (Lindsay's nails), lung disease (nail clubbing), endocarditis and many others.

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Introduction to the Hand Exam

Consider beginning all physical examinations by reaching for the patient's right hand with both of yours. Inspect it and then move to the radial pulse. This is a nice way to ease into the examination; you are beginning with the equivalent of a handshake.

Inability to let go your of hand (think myotonia, not to be confused with the grasp reflex in frontal lobe disease. Look for other signs of myotonic dystrophy: hatchet face, cataracts, baldness, myopathic facies).

Beau's Lines

Muehrcke's Lines (Leukonychia striata)

Narrow while transverse lines (Not depressed, compared to Beau's lines). Usually 2 or more lines on one nail. Seen in states of decreased protein synthesis or increase protein loss such as with hypoalbunemia (usually less than < 2.2 g/dL), certain chemotherapy and nephrotic syndrome. (Image Credit)

Mees' Lines

Transverse while lines (usually one per nail, no depressions) that often can will disappear if pressure is placed over the line. It is strongly associated with arsenic poisoning, thallium poisoning and to a lesser extent other heavy metal poisoning. (Image Credit)

Acral Lentiginous Melanoma (involving nail)

While acral lentinginous melenoma is often seen anywhere on the palms, soles, and even in the mouth, when it occurs within the nail, a clue that this is melanoma is involvement of the periungal regions as seen in this picture.

Nail Pitting

Quitter's Nail

Nicotine stained distally, but not proximally with clear line of demarcation. See also our article in Chest and NEJM clinical image. May also appear when pt switches to "lower tar" tobacco.

Finger nails grow at a rate of about 0.8-1.0 mm per week. Using this, you can approximate when the clinical scenario causing the nail finding occurred. For example, approximating when someone has stopped smoking who has quitter's nails.

Clubbing

Lung Cancer (clubbing is in general an ominous sign for this, and remember "beware of the yellow clubbed digit". (Yellow from nicotine, and clubbed from cancer).

Pus in the lung (bronchiectasis as in CF, but also lung abscess and empyema)

Pulmonary Fibrosis

COPD IS NOT A CAUSE OF CLUBBING (if you seen clubbing in a COPD patient, think lung cancer)

Heart

R to L shunts

Endocarditis

Pericarditis

There are other causes of clubbing, outside the heart and lungs, but these are the important ones.

If a patient has painful wrists, painful ankles and comes to see you and you miss that they also have clubbing, you will go down the wrong path looking for RA etc, when what they have is Hypertrophic Pulmonary Osteoarthropathy. The causes of HPOA are the same as those of clubbing.

Pseudoclubbing: distinguished from clubbing by the preservation of the nail-fold angle and bony erosion of the terminal phalanges on radiography. Pseudoclubbing is also more likely to be asymmetric.

Mechanical Dysfunction of the Hand

Pope's Hand (Hand of Benediction)

The pope's hand is seen with median nerve dysfunction when asking the patient to make a fist due to inability to flex 1st & 2nd fingers at PIP. The median nerve controls the 1st & 2nd lumbricals, three thenar muscles (abductor pollicis brevis, flexor pollicis brevis, and via a distal branch the opponens pollicis).Additionally theremay be thenar atrophy. (Image Credit)

Ask patient to use both hands to make and "Okay" sign by forming a circle with thumb and index finger. Median nerve palsy may make one hand produce a pinched circle (right hand in image). (Image Credit)

Froment's Sign

Ask patient to hold a piece of paper between thumb and index finger. If the examiner can pull paper away (a positive Froment's sign), it suggests that an ulnar palsy has weakened the thumbs strength of opposition.

Misc. Hand Findings

Herpetic Whitlow

Bouchard's and Heberden's Nodes

Bouchard nodes (found at the PIP) and Heberden's nodes (found at DIP) are bony outgrowths seen in osteoarthritis (DJD) of the hand. These outgrowths are formed by calcific spurs within the respective articular joint.

Tripe Hand

Down's syndrome

Single palmar crease (Simian crease). The fifth digit is abnormally short (only reaches the second crease of the 4th digit). Remember to look for endocardial cushion defects (ASD, VSD and mitral/triscuspid abnormalities).